I understand that I will be participating in a telehealth consultation with Kate Quinn Stewart, L.Ac., and that I will be provided services via an online or mobile phone experience. I understand that this is called “telehealth,” as I will not be in the same location as the person providing the services.
I understand that phone conversations and the video-conferencing platform(s) used by my provider are compliant with HIPAA regulations. I understand that health information shared or documented during telehealth services will be kept confidential.
I understand that there are risks to this use of technology including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth consultation if it is felt that the video-conferencing connections are not adequate for the situation.
In case of technical difficulties with the video-conferencing platform, I am aware that I can:
- Call my practitioner by phone at 703-520-7142
- Use the help or troubleshooting resources provided by the video-conferencing platform
I understand that there are two types of telehealth services offered by Nurturing Spirit Acupuncture.
1) "New Patient Virtual Intakes" are scheduled prior to new patient office visits and are for the purpose of sharing my health history, current health issues, and goals for change with treatment. Providing this information will help my acupuncturist design a treatment plan that is suited to my individual needs.
2) “Virtual Wellness Sessions,” will involve learning or being guided through various techniques and practices intended to help me support my own health and wellbeing. These may include self-acupressure, self-massage, qi gong (coordinated breath and movement practices), breath practices, relaxation techniques, guided imagery, suggestions for the therapeutic use of essential oils, dietary and lifestyle recommendations based on Chinese medicine principles, and/or Chinese herbal medicine consultation**.
I understand that it is my responsibility to immediately inform my practitioner if I experience any pain, discomfort, or adverse effects during a telehealth session. I understand that if I am uncomfortable with any approach, technique, or practice used during a telehealth session, I have the right to ask the practitioner to modify or stop whatever is creating the discomfort. I understand that in the unlikely event that emergency circumstances arise during a telehealth session, my practitioner will advise that I seek urgent or emergency care that is local to me or that I call 911. I understand that telehealth services are not an appropriate medium for addressing emergency medical concerns.
I understand that care, treatment, and services provided by Kate Quinn Stewart via telehealth or in person are not a substitute for care, treatment, and services provided by a licensed physician.
I understand that it is my responsibility to inform my practitioner about all aspects of my health, any medical conditions I may have, and any changes that occur in my condition either during the telehealth session or between sessions.
I acknowledge that I am ultimately responsible for my own health and self-care. Making healthy lifestyle choices can substantially support my health and wellbeing and will enhance the outcome of my virtual wellness sessions and/or acupuncture treatments. I understand that each individual responds uniquely and therefore my practitioner cannot guarantee the outcome of a virtual wellness session or use of the practices demonstrated therein.
I understand that, because I am initiating telehealth services without having had a prior in-person assessment, a full Chinese medicine diagnosis will not be possible, as this involves the practitioner feeling the pulses and performing other hands-on evaluations. These sessions will be for the more general purpose of supporting my overall health and wellness. I also understand that because there has been no prior in-person visit, my virtual wellness sessions will not be eligible for insurance reimbursement.
I understand that I will receive a bill for these telehealth services and I am responsible for payment regardless of my ability to obtain insurance reimbursement. Virtual wellness sessions will be billed separately. The fee for the virtual check-ins will be included in the fee for my in-person acupuncture visit.
**Chinese Herbal Medicine
The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that are recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy or in the case of significant changes in my health condition. I will notify my acupuncturist if I am, or become, pregnant, or if I am nursing, or if I have significant health changes, a new diagnosis, or new prescription medications. Should I become pregnant, I will discontinue all herbs and supplements until I have consulted and received advice from my acupuncturist and/or obstetrician. I understand that I must inform, and continue to fully inform, this office of any medical history, family history, medications, and/or supplements being taken currently (prescription and over the counter).
I understand that the herbs may need to be prepared and the teas, tinctures, pills, or topical preparations should be consumed/applied according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. Some possible side effects of taking herbs are: nausea, gas, stomachache, vomiting, liver or kidney damage (very rare), headache, diarrhea, rashes, hives, and tingling of the tongue. I will immediately notify my acupuncturist of any unanticipated or uncomfortable effects associated with the consumption of the herbs.
I affirm that:
- I have read this form or had it read and/or explained to me.
- I fully understand its contents, including the risks and benefits of telehealth services.
- I have had the opportunity to ask questions and that my questions have been answered to my satisfaction.
- By signing below, I hereby give consent to telehealth as an acceptable form of delivering healthcare services to me and that this consent will cover any and all of my sessions using telehealth services.